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Selecting Appropriate and Effective Equipment

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Choosing the right equipment
Mobility Purpose Design
Painful sitters Difficulty with proper alignment

Orthopedic Issues
Loss of passive joint mobility Fixed contractures Loss of stability Scoliosis

Optimizing the environment
House School Recreation Car

Mobility

Important determinants of ambulation potential
Energy Expenditure Spasticty Contractures Pain

Ambulation Categories
Community Household Exercise Nonamulatory

Community ambulators
Pelvic control with at least fair strength in hip flexors bilaterally and in at least one knee extensor

Potential benefits
Ability to overcome functional barriers Increased self esteem Cardiopulmonary exercise

Neurologic predictors for ambulation
Level of injury below T11 associated with increased potential for ambulation Complete tetraplegia do not become “community” ambulators Chronologic age is not by itself a prognostic factor

Mechanical devices to assist ambulation
Hip-knee- ankle-foot orthosis (e.g. reciprocating gait brace) Knee-ankle-foot orthosis (e.g. Scott-Craig brace) Ankle-foot orthosis

Rehabilitation for ambulation training
Strengthening of the lower and upper extremities Control of the pelvis and trunk Joint stabilization

Goals
Prevent or accommodate orthopedic deformities Prevent skin break down from pressure Provide trunk stability to enhance arm function Promote independent mobility Facilitate independence in the activities of daily living

Planning a seating system
Angle between the seat and the back surfaces Tilt of the system in space Type of seating surface

The Angle
Whatever is needed to
maintain the pelvis in an neutral or slights anterior pelvic tilt achieve the proper lumbar curve provide a base for good spinal alignment

Opening the angle (making it more than 90 degrees)
At 90 degrees of hip flexion need to be available Over 90 degrees may reduce spasticity But may also destabilize trunk support May force low back extensors to “fire” increasing lumbar curve

Using head, shoulder, and back extensors to remain upright

Upright support options
Anterior harnesses or chest straps Upper extremity support like a tray Tilting
slight tilt may be enough to sit more upright against gravity

A slight tilt may help sit more upright against gravity

Tilt-in-space base
Provides adjustment for seat tilt while holding hip, knee, and ankles in place

The Seat
Planar Contoured Custom molded

Sitting on flat surfaces may cause increased pressure over bony prominences

Some types of foam will reshape in response to body weight

Blocks can be added to the sitting surface to provide lateral as well as posterior supports

High density foam shapes can be placed under more flexible foam to create a contoured cushion

Seat Surface
Does the seat provide enough support? Is the seat the proper depth? Does the seat provide enough pressure relief?

The pelvis and lower extremities
A firm base of support is needed from which to function The base needs to be
Stable Symmetric Supportive

The pelvis position should be neutral or slightly tipped forward

Posterior pelvic tilt affects body posture
Discomfort Finding a balance point Shortening of the hamstring muscles

Falling into anterior pelvic tilt
Weakness Very low tone Hip flexion contractures

Sitting in a sling seat increases asymmetries

Firm sitting surface provides a good base of support

Back Surface
Does the back surface provide enough support? Is the seat the proper depth? Is the back support high enough?

Support to the back of the pelvis can help maintain good alignment

If the seat is too deep then the pelvis will tilt back causing the pelvis to round

Is the back support high enough?
Fair trunk control – should rise to the middle of the shoulder blade Poor trunk control – should rise to the shoulder Increase extensor tone – should rise to the shoulder

Positioning belts or bars are used to prevent the pelvis from slipping
A belt across the waist will encourage posterior pelvic tilt

A rigid bar may be needed with excessive trunk extension

Hip guides to control pelvic position

Knee supports
A “spacer” may be needed to keep the legs in a neutral position It should start at the front of the knee and move 1/3 of the way up the thigh

Trunk supports
Leaning to one side or the other
Muscle imbalance Poor postural control Discomfort Perform a functional task

Three point control is needed to maintain trunk position

Proper position of the straps is very important
The strap should pass over the shoulder to a point at or slightly below the shoulder line The bottom should be securely tethered

Y straps tend to bind against the side of the neck putting pressure over neck blood vessels

H straps work well but should not be tethered to the lap belt

Standing Frames

Gait trainers

Orthopedic surgery: Should we or shouldn’t we?

Decisions to treat
Based on degree of contracture Whether the joint motion covers a “functional” range Belief that surgery will improve the natural history

Common Clinical Patterns: Lower Limbs

Physiology of Contractures
Mobile tissues usually separated by thin layers of loose areolar connective tissue Immobility causes reorganization of the loose connective tissue Once soft tissues are involved - muscle shortening may follow

Orthopaedic surgery
3 major goals
Remove or diminish muscle imbalance Prevent bony deformity Correct bony deformity

Orthopaedic Surgery: Goals
Muscle-tendon surgery
restore dynamic alignment improve agonist-antagonist balance

Osteotomies
realigns osseous levers correct torsional deformities

Arthrodesis
stabilize severely subluxed, painful arthritic joints

Musculotendinous Procedures
Lengthening of the tendon
Tendo Achilles lengthening Hip adductor tenotomy

Lengthening of the musculotendinous junction or fascia
Strayer, Vulpius, or Baker lengthenings

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Defining the functional problem
Joint contracture: loss of passive range of motion
muscle-tendon unit
dynamic which is braceable fixed which requires surgery

ligament or joint capsule

Gait deterioration Joint instability or torsional deformity Pain